South Dakota Medicaid requires prior authorization for genetic testing, and the ordering provider requests it on form PA-106. The form must be sent with medical records supporting medical necessity. Its second page asks the clinician to explain how a positive or negative result would change the recipient's plan of care, and to estimate how common the suspected condition is and how likely the recipient is to have it.
The ordering provider completes the form, including the facility or clinic, anticipated date of service, diagnosis and procedure codes, the referring and servicing providers, and the clinical questions on page 2.
Download the current version from the source each time; forms change without notice.
Prior Authorization Request Form: Genetic Testing
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form asks how the outcome will affect the recipient's plan of care if results are positive or negative, with specific medications, therapies or further screening. It also asks for the prevalence of the suspected condition in the population and the recipient's likelihood of having it, both as percentages.
The Division of Medical Services has 30 days to make a prior authorization determination and says most take around two weeks. Prior authorization applies only to elective services, and the determination notice is sent to the point of contact listed on the form.